Provider Demographics
NPI:1407060718
Name:RIVERA, DIANI IVETTE
Entity Type:Individual
Prefix:
First Name:DIANI
Middle Name:IVETTE
Last Name:RIVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB.LOS FLAMMBOYANES 262 MAGA ST
Mailing Address - Street 2:
Mailing Address - City:GURABO
Mailing Address - State:PR
Mailing Address - Zip Code:00778
Mailing Address - Country:US
Mailing Address - Phone:787-739-0594
Mailing Address - Fax:787-274-8477
Practice Address - Street 1:URB.LOS FLAMMBOYANES
Practice Address - Street 2:262 MAGA ST
Practice Address - City:GURABO
Practice Address - State:PR
Practice Address - Zip Code:00778
Practice Address - Country:US
Practice Address - Phone:787-739-0594
Practice Address - Fax:787-274-8477
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR004778183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR004778Medicare UPIN